An 81-year-old female maintained on warfarin for
a history of chronic atrial fibrillation and mitral valve
replacement developed asymptomatic runs of ventricular tachycardia
while hospitalized. The unit nurse contacted the physician, who was
engaged in a sterile procedure in the cardiac catheterization
laboratory (cath lab) and gave a verbal order, which was relayed to
the unit nurse via the procedure area nurse. Someone in the verbal
order process said "40 of K." The unit nurse (whose past clinical
experience was in neonatal intensive care) wrote the order as "Give
40 mg Vit K IV now."

The hospital pharmacist contacted the physician
concerning the high dose and the route and discovered that the
intended order was "40 mEq of KCl po." The pharmacist wrote the
clarification order. However, the unit nurse had already obtained
vitamin K on override from the Pyxis MedStation® (an automated
medication dispensing system) and administered the dose
intravenously (IV). The nurse attempted to contact the physician
but was told he was busy with procedures. A routine order to
increase warfarin from 2.5 mg to 5 mg (based on an earlier INR) was
written later in the day and interpreted by the evening shift nurse
as the physician’s response to the medication event. The
physician was not actually informed that the vitamin K had been
administered until the next day. Heparin was initiated and warfarin
was re-titrated to a therapeutic level. The patient’s INR was
subtherapeutic for 3 days, but no untoward clinical consequences
occurred.

The Commentary

by Timothy S. Lesar, PharmD

This case illustrates how seemingly low-risk
patient care activities create the opportunity for serious errors
to occur. The initiating event in this case was a breakdown in
communication during the ordering of a medication ("40 of K").

Telephone and Verbal Orders

The use of verbal or telephone orders is cited as
an error-prone process by the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) (1),
the Institute for Safe Medication Practices (ISMP) (2), and the National Coordinating Council for Medication
Error Reporting and Prevention (NCCMERP).(3) A key 2003 JCAHO Patient Safety Goal (1) is to minimize the use of verbal or telephone orders,
but if used, the order should be immediately transcribed and read
back for confirmation. The common perception of increased risk has
prompted many hospitals to implement policies restricting such
orders to urgent medical situations. The data on errors with verbal
orders, however, is mixed. One recent study found an increased risk
of hospital prescribing errors when orders were verbally
transmitted or were transcribed by nurses.(4) However, the only systematic evaluation of error risk
by mode of transmission found that verbal and telephone orders
carried a similar or lower error risk than written orders. Verbal
orders did have increasing error rates as the order complexity
increased, something not seen with written orders.(5)

Sending Messages Through a Third Person and
"Multitasking"

Another possible contributing factor here was the
transmission of the order via a third person (the procedure area
nurse). Moreover, the physician gave the order while performing a
procedure in the cath lab. Communicating through a third person
while "multitasking" not only increases the risk of
miscommunication, but also reduces the effectiveness of the
confirmation process and lessens the likelihood that effective
communication occurs if questions arise about the order.

Abbreviations

Abbreviation use contributed to the
miscommunication in this case. The abbreviation "K" led to
administration of the wrong drug. Such short cuts place patients at
unnecessary risk for error. The contribution of abbreviations to
medication error is well documented, and several organizations
recommend that abbreviation use therefore be restricted or
limited.(1,6-8)
JCAHO now requires that health care organizations establish a list
of prohibited abbreviations (1) and
that such organizations implement policies to reduce risk from
resultant communication errors. Abbreviation of dose units, dosage
form, dose routes, dose rates, and frequency will similarly produce
errors in drug orders, and should be avoided.

Knowledge, Culture, and Communication

An additional, and equally important,
consideration in this case is the nurse’s failure to attempt
to verify the appropriateness of an order that she considered
questionable. The transcribed order for "40 mg vitamin K IV now"
was rationalized as appropriate rather than confirmed with the
prescriber. The underlying reasons for this are multiple. Caregiver
knowledge and access to patient and drug information is often
inadequate to accurately and efficiently evaluate medication orders
for appropriateness.(9)
When an order is not clearly wrong, many caregivers will
rationalize a questionable order by deferring to the knowledge of
the prescriber. Cultural and interpersonal factors also play a
role. Hesitancy to challenge or question prescribers may be a
cultural norm within the organization. Difficult or intimidating
prescribers create hesitancy among providers to discuss potential
issues. Even creating the perception that the prescriber is "busy"
will reduce the likelihood that caregivers will question an order
they are not certain is in error. As a result, questionable orders
may be honored without contacting prescribers for verification.

Particularly telling in this case is the fact
that the physician was not promptly informed of the error. The fear
of openly communicating the error could have resulted in
significant patient harm. When errors are not immediately
communicated, the risk to patients is greatly increased, and the
opportunity to ameliorate potential harmful effects is missed. High
reliability organizations such as the airline industry and military
have striven to decrease risk of accidents by reducing "authority
gradients" and promoting effective teamwork and communication.
Caregivers likewise must view the fostering of open and effective
communication to be an essential patient safety function. Behaviors
that inhibit communication place patients at greater risk for an
adverse
drug event (ADE). Caregivers should be coached in techniques
for communicating and resolving conflicts.(10) The ADE described here might have been avoided if the
nurse had improved decision support for order evaluation or if the
culture had strongly supported questioning any order in doubt.

No Pharmacist Order Review and Uncontrolled
Automatic Dispensing Cabinet Medications

Pharmacist review of medication orders is a key
safety procedure whose benefits have been demonstrated.(11)
Except in medically urgent situations in which a delay presents
possible patient harm, JCAHO standards (12) require that pharmacists review medication orders
prior to administration. When not performed (ie, due to emergency),
order review should occur as quickly as possible. In this case, the
pharmacist review detected the error, but it was too late.

While rapid provision of drug therapy is
sometimes critical, the important safety step of pharmacist review
is often bypassed unnecessarily for sake of "efficiency." Automatic
dispensing devices (ADDs) (Figure 1, Figure 2), in which medications may be accessible to
caregivers prior to pharmacist review, are used in almost 60% of
hospitals (13) as
a method of drug distribution. Despite widespread use of ADDs,
information regarding their impact on patient safety is limited.
Available studies demonstrate that ADDs might reduce "wrong time"
(usually late) medication errors, but possibly increase risk for
more serious wrong drug and wrong dose errors.(14) The ISMP Medication Safety Alert! (available at:
http://www.ismp.org/MSAarticles/msa.html) has reported
serious and fatal medication errors resulting from uncontrolled
access to medication from ADDs. The uncontrolled access is provided
by either failing to have the device interfaced with the pharmacy
computer (the interface allows only pharmacy-approved medications
be available), or by using an "override" process, which is meant to
provide a method for caregivers to gain access to medications
quickly in an emergency. JCAHO standards require that overrides be
carefully controlled and limited to urgent situations. In 2002,
however, US hospitals reported that 22.8% of all doses dispensed
from ADDs were obtained using overrides.(13) Clearly this number far exceeds what one would expect
if the process were used only for medically urgent situations. One
550-bed hospital reported that more than 75 overrides occurred each
day for antibiotics alone. Review of these overrides demonstrated
an error rate of 21%, mainly due to obtaining antibiotics after the
drug was discontinued.(15)

To reduce risk to patients, organizations must
carefully evaluate and control which medications are provided in
ADDs prior to pharmacist review. Factors to consider include the
care setting, patient types, risk for error, drug product
characteristics, type of ADD, and ability of pharmacy to supply the
medication in a timely fashion. Whenever medications are accessible
from ADDs or other uncontrolled medication supplies, clear policies
and procedures should exist regarding when medications can be
accessed. Appropriate safety procedures such as warnings, limiting
medication amounts, special labeling and packaging, second person
double checks, staff education, and process oversight must be in
place. When medications must be obtained from an ADD and
administered prior to pharmacist review, the order should be sent
to the pharmacy for review as soon as possible.

Take-Home Points

All medication orders create an
opportunity for error. Whenever feasible, defer all necessary
prescribing until the safest possible conditions exist.

Limit the use of telephone and verbal
orders. Always request a "read-back" of the
transcribed order.

Communication between caregivers is
critical for patient safety. Prescribers should actively encourage
communication and welcome the questioning of their orders.

Pharmacist review of medication orders
reduces risk of error and should not be circumvented for
convenience.

Automated dispensing devices have not
been shown to improve patient safety, and may increase patient risk
if not wisely implemented. Accessing medications from ADDs prior to
pharmacist order review and release circumvents the traditional
safety constraints of medication control.

3. National Coordinating Council for Medication
Error Reporting and Prevention. Recommendations to reduce
medication errors associated with verbal medication orders and
prescriptions. February 20, 2001.
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